1、Chronic Renal InsufficiencyLu FumingDivision of Nephrology,Huashan Hospital,Fudan University 1Chronic Renal InsufficiencyPathogen and pathogenesisManifestationLaboratory examinationDiagnosis and differential diagnosisTreatment2Etiology primary glomerular diseases hypertensive nephrosclerosis diabeti

2、c nephropathy chronic pyelonephritis multicystic kidney systemic lupus nephritis3PathogenesisMechanism associated with exacerbation of renal functionMechanism associated with uremic symptom4Mechanism Associated With Exacerbation of Renal FunctionHyperfiltration theoryEffect of proteinuriaTrade-off h

3、ypothesis in acidosisDisturbance of lipid metabolismTubulointerstitial injuryRenal hypoxia5Mechanism Associated With Uremic SymptomUremic toxinsmalnutritiontrade-off hypothesisEndocrine dysfunction6Manifestation of the Uremic SyndromeGastrointestinalCardiovascularHematologicPulmonaryNeurologicDermat

4、ologicEndocrinologicophthalmic7Gastrointestinal ManifestationAnorexia progressing to nausea and vomitingStomatitis and gingivitisParotitisPeptic ulcer diathesisGastritis , duodenitis and enterocolitisPancreatitisAscites8Cardiovascular ManifestationAccelerated atherosclerosisCardiomyopathypericarditi

5、s9 Hematologic ManifestationAnemiaAltered neutrophilic chemotaxisDepressed lymphocyte functionPlatelet dysfunction10Pulmonary ManifestationAtypical pulmonary edemaPneumonitisFibrinous pleuritis11Neurologic ManifestationCentralDaytime drowsiness,a tendency to sleep,comaDecreased attentivenessSeizures

6、Disorientation and confusionPeripheralRestless leg syndromeSensorimotor peripheral neuropathyIncreased muscle fatigability and muscle cramps12Dermatologic ManifestationPruritusDystrophic calcificationChanges in skin pigmentation13Renal Osteodystrophy high bone turnover disease low bone turnover dise

7、aseMixed bone disease 14Endocrinologic ManifestationSecondary hyperparathyroidismInsulin resistanceType IV hyperlipidemiaAltered peripheral thyroxine metabolismTesticular atrophyOvarian dysfunction15Disturbed Water, Electrolytes and Acid-base BalanceWater loss and water intoxicationHypo- or hyper-na

8、tremiaHypo- or hyper-kalemiaHypo- or hyper-calcemiaHypo- or hyper-phosphatemiametabolic acidosis16Experimental TestUrine testBlood testRenal function testBlood biochemical testRadiologic and ultrasonographic test17Diagnosis and Differential DiagnosisDiagnosis of chronic kidney diseaseEtiologic diagn

9、osisDifferential diagnosis 18Stages of Renal Insufficiency stage GFR SCr clinical manifestation (ml/min) (umol/L)compensated stage 5080 133 asymptom azotemia 25-50 445 nycturia , anemia renal failure 10-25 800 nausea,anemia, acidosis uremia 800 obvious uremic symptom19Definition of Chronic Kidney Di

10、seaseRenal injury: 3 monthsDecreased GFR: yes or no Renal injury: abnormal experimental testsGFR3 monthsRenal injury: yes or no 20Stages of chronic kidney diseasestage description GFR management 0 high risk for CKD 90 find out the risk factors 1 Renal injury,normal GFR 90 diagnosis,treat complicatio

11、ns2 Lightly decreased GFR 60-89 evaluation of progressing3 Moderately decreased GFR 30-59 treat complications Severely decreased GFR 15-29 ready for renal replacement uremia 15 renal replacement21History Physical examinationExperimental testRadiologic and ultrasonographic examinationRenal biopsyEtio

12、logic diagnosis22Differential diagnosisWith acute renal failureHistory : long or shortChanges in urine volumeChanges in HbDermatologic manifestationBone diseaseChanges in SCrLength of the kidney23TreatmentEtiologic treatmentTreatment without dialysisDialysisRenal transplant24Etiologic treatmentProgr

13、ess of primary diseasehypoperfusionHeart failurehypertensionhyperlipidemiainfectionNephrotoxical drugObstructed urinary tractstressSevere anemiaDisorder of electrolytesHigh protein diet25Treatment without dialysisnutritional therapyTreat cardiovascular complicationsTreat anemiaTreat renal osteodystr

14、ophyKeep the balance of water,electrolytes and acid-base26Nutritional TherapyEnergy intake30-35 kcal/kg/dayProtein intake0.6g/kg/dayNecessary amino-acidVitaminsVitC、VitB6VitD27Treat cardiovascular complicationshypertensionHeart failurepericarditis28Treatment of anemiaErythropoietininitial：100u/kg/week，divide in 2-3 dosageIncrease 50% dosage：Hct increase 8% per monthtarget： Hct 33%-36% Hb 1112g/dlIron supplementtarget： SF100, saturated TRF 20% oral： 200mg iron/dIntra venous：100mg iron per HD，total 10 timestarget reached：25125mg iron per week